The Debt Ceiling and Health Care

Over the weekend, I watched Twitter as drops of information about the debt ceiling leaked out bit by bit. There was a deal. No deal. Well, maybe a deal.The deal would require Congress to wait until a Balanced Budget Amendment passed in the states before it acted. Well, no it actually didn’t include that. Medicare was on the chopping block. Well, not cuts to members, only cuts to physicians and other providers. What’s an ordinary person to think?

There was plenty of humiliation to go around. Speaker Boehner didn’t return the president’s phone calls. Speaker Boehner couldn’t rally his own party to support his deal. Majority Leader Reid couldn’t get Republicans to talk to him. Sen. McConnell would only talk to Biden not Reid, and his unfortunate facial expressions left us with the impression that he had a serious digestive problem. The classic picture was Boehner in the House elevator letting out a long groan as the doors closed. He was not the only one groaning.

Pundits made the worst cliché pronouncements. Everything was a “crisis”; there was lots of “kicking the can down the road.” TV time had to be filled and fill it they did. Those smart folks who spent the weekend outside, barbecuing or swimming, were the wise ones. We all knew it would come down to the last moment, but oh, was it painful to watch those last agonizing hours.

Now that the debt ceiling will be raised and we can pay our bills (for a while at least), we are left to wonder — what will it really mean for some of the programs we care about? The predictions have ranged from death to resurrection for Medicare and Medicaid. But somewhere in this pile of doo-doo there may be a few ponies. The details of the debt ceiling “deal” require that some programs be kept off the table in the negotiations of the “super committee.” Those programs include Medicaid (remember almost half of Medicaid goes to nursing home care and the rest to health benefits for the disabled, poor women and children, and the elderly), Social Security, military salaries, and veterans’ benefits. Cuts to Medicare cannot affect “benefits” (although the committee can raise eligibility age and potentially copayments), only payments to providers. The military and Homeland Security are not exempt as they have been in the past.

While there is some protection for the programs that serve our most vulnerable citizens, it is hard to claim that these are victories we should cheer about. Some of the key aspects of the health reform law may be affected negatively by the need to make these deep budget cuts. Funding for the subsidies that will allow people of limited income to get health insurance in 2014 may be severely constrained. The new Independent Payment Advisory Board (IPAB), which has been under fire for some time, may be eliminated, leaving decisions about how to contain costs in Medicare to the politicians — the same politicians that have proven themselves unable to do that very thing up to this point. While many of the health reform law’s provisions are already being implemented (e.g. closing of the donut hole in prescription drug coverage for seniors, allowing young adults to stay on their parents’ plan until 26, tax credits for small business to help them provide coverage, the establishment of state-based exchanges, demonstration programs to cut costs and maintain quality in Medicare — to name a few things), the full roll out of the law very much depends on who wins what in 2012. If the Republicans keep the House, win the Senate and the Presidency, the ACA will most definitely be repealed.

Meanwhile? There is no Republican plan to fix health care, other than Rep. Ryan’s proposal to give seniors some money and toss them into the health insurance marketplace to find coverage. Oh yes, and more “personal responsibility” for health care, translated as shifting costs to us and requiring us to try to figure out which doctor or hospital is cheaper and better, when that is almost impossible to do with the information we currently have. The trifecta of Republican options remains the same: 1) personal responsibility 2) malpractice reform and 3) selling insurance across state lines. Have these solutions brought down health care costs? Not so much.

I am generally a pretty optimistic person. If you read my blogs, you know that I try to find something positive in almost every aspect of health reform, even though many of you have tried to disavow me of that optimism and have accused me of pollyanism or worse! Still, I have found plenty of ponies in the last several years — the bookstore owner who was able to give her employees coverage because of the tax credit; the family whose son had cancer but could keep him on their insurance plan while he underwent chemotherapy; the savings for seniors from the closing of the donut hole for prescription drugs; the state programs for people who are uninsurable.

What I tell my family and friends now is the following: 1) This is not the worst deal ever. There are some wins for health care programs and some small potential for meaningful tax reform. 2) If you care about keeping Medicare and Social Security solvent you need to speak out and organize, but also be willing to be flexible about what changes to those programs will keep them solvent and 3) While you may not think that the president negotiated as well as he could have, we don’t really know all the details and the background of what went down. I do think it could have been worse and so do manyothers.

Linda Bergthold, PhD, is an independent health policy consultant and researcher and Senior Advisor at the Center for Medical Technology Policy. She currently serves as on various boards and committees to evaluate new technologies and review research from the consumer perspective. Follow her on Twitter: @lab08

Appointing senators was intended to minimize the public (rabble) influence on government. Considering that most “representatives” in congress seem more concerned with their patrons and their own hides right now, there’s no worry of excessive influence of citizens on government right now.

What is melting down is unbridled selfish capitalism and myopic avarice which advocates keeping the unethically obtained fruits of other people’s labor under the mansion floor instead of sending some to Washington where it could be put to good public use and bring you even more cash in the long run.

…and this will help you/us in some way? maybe it’s time to appoint presidents too…..

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Peter

Aug 4, 2011

“Medicare canpay whatever it wishes. The patient should be on the hook for the rest.”

Ah yes, provider prices/utilization is not part of the problem, it’s all the patients’ fault. Certainly wouldn’t want any income reductions for providers who can set whatever price they want.

“Time for the gov’t to get out of the direct benefit game. It was never their call to be rescuing people from life’s misfortunes.”

I guess that would include FEMA bailouts for so called, “natural” disasters? The states would be the first to scream. Strange you also want the “government” to rescue you from the life misfortune of lawsuits.

“Doctors used to have the stature to tell the family to let grandma go.”

That’s just bunk. Maybe the other docs at your facility don’t have the “stature” but the ones at my wife’s hospital do it all the time, even bringing in the hospital chaplain. Do you want docs overriding the wishes of family/patient? How would you enforce “stature”? Dems tried to do it in ACA with end-of-life directives and got nothing but screaming scorn from Repugs and religious fanatics – oh sorry, that’s “rear view mirror”. I guess we’ll see Repugs proposing that now since it’s such a good idea.

“Time to appoint senators again.”

There’s a democratic by the people solution. Just who would do the “appoint’n”.

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MD as HELL

Aug 4, 2011

The legislature of each state used to appoint the senators. That was the last time the country had balance between atate and federal government.

Only the government can create the litigation hazard for me, so only the government can rescue me from it.

FEMA is a joke. Natural disasters are the business for the states.

Time to dismantle Soc. Sec. and Medicaare.

They are toast as soon as the younger voters get tired of carrying your dead wood.

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MD as HELL

Aug 3, 2011

That would be larger provider bills and balance billing. Medicare canpay whatever it wishes. The patient should be on the hook for the rest.

I promote death with dignity all the time. i preach against feeding tubes case by case all the time. Doctors used to have the stature to tell the family to let grandma go. Then consumerism took over around 1988. Customer ssatisfaction rose its ugly and unprofessional head at the same time. The malpractice crisis took off. It all costs.

Futile end of life care should not be publicly financed.

The Republicans are politicians, too. They did a bad job. Get out of the rearview mirror. The screwups of the past do not excuse the screwups of today and tomorrow.

In gambling they say “bet with your head, not over it.” The gov’t is so far over its head with unfunded polital promises, it can bring down the whole country.

Time for the gov’t to get out of the direct benefit game. It was never their call to be rescuing people from life’s misfortunes.

Time for the states to bring down the tail wagging the dog.

Time to appoint senators again.

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Tracy

Aug 3, 2011

Wwll I partially agree with the thrust of the blog, it seems like one important element is missing and that is to do the will of the people who elected the Congress.

Also, many of the reforms passed by Congress and called healthcare reform were actually already passed in many states years in advance of Obamacare. As someone who has dealt in healthcare and specifically health insurance for nearly 25 years, these reforms were not a game changer.

The game changer will come if we have the courage to take on malpractice reform. That will be the cost shifter or game changer.

Thanks

Tracy

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Peter

Aug 3, 2011

“It is time to stop buying scooters and time to stop placing feeding tubes for futile end of life care.”

I’d have to agree on the scooters, “at no cost to me”, but who would you give the authority to decide tube/no tube that would get past the right-to-lifers? The ACA did have in it provision to promote living wills but your cherished Teapublicans screamed DEATH PANELS!!!

“It is time for nursing homes to not send me every patient they find uninjured on the floor.”

Would you remove liability for nursing homes?

“It is time for the growth in government healthcare outlays to shrink.”

Would that include smaller provider reimbursements?

“It is not the job of the Republicans to “fix” healthcare until they control the Senate and the White House.”

But is it the job of Teapublicans to block all attempts at reform by Democrats and the White House? Did Republicans fix health care when they held control? Who rammed through Med part D as another entitlement?

I think the real issue is not the debt or the money. For one we are a non social-welfare state. Looking at the experience of social welfare states in Europe one can indeed see that half the problems of health care related debts is the lack of the government’s initiative to put health before business. Right now it is the insurance companies that are raking in the moolah in the name of healthcare, not to mention the ongoing bleeding of insurance money through fraud. Welfare state would also put a lot of other things in line with keeping our debt under control

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MD as HELL

Aug 3, 2011

The super committee will end up with no power at all. Continuing to borrow to fund mindless healthcare is insane. No one should have public debt incurred for healthcare costs live linger than they do.

It is time to stop buying scooters and time to stop placing feeding tubes for futile end of life care.

It is time for nursing homes to not send me every patient they find uninjured on the floor.

It is time for MediCare preadmission denials to mean something.

It is time for the growth in government healthcare outlays to shrink.

It is not the job of the Republicans to “fix” healthcare until they control the Senate and the White House. It is the job of the Democrats to shrink entitlements and to fix healthcare.

This has been a terrible debt deal. Not nearly enough cuts, and taxes will go up in record fachion in 2013.

A 2004 photo shows Air Force Staff Sgt. Dean Witt with his wife, Alexis, after a mistake at a military hospital left him in a vegetative state. His family is fighting a law that has protected the hospital from a negligence lawsuit.
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BRADENTON, Fla. — Veterans, military families and others who oppose a decades-old law that shields military medical personnel from malpractice lawsuits are rallying around a case they consider the best chance in a generation to change the widely unpopular protection.

The U.S. Supreme Court will decide next month whether to hear the case of a 25-year-old noncommissioned officer who died after a nurse put a tube down the wrong part of his throat.

If the law is overturned, it could expose the federal government to billions of dollars in liability claims. That makes it highly unlikely a divided Congress desperate to cut expenses will act on its own to change what’s called the Feres Doctrine, a 1950 Supreme Court ruling that effectively equates injuries from medical mistakes with battlefield wounds.

The court case involves the death of Air Force Staff Sgt. Dean Witt, who was hospitalized in 2003 for what should have been a routine appendectomy at Travis Air Force Base in Fairfield, Calif. After surgery, a nurse anesthetist inserted a breathing tube into his esophagus instead of his trachea, or airway, depriving his brain of oxygen. Witt, of Oroville, Calif., died once his family removed him from life support three months later.

The nurse admitted her mistake and surrendered her state license. Federal courts denied the legal claim by Witt’s widow, saying their hands were tied by the Feres Doctrine. Witt’s family appealed, aiming to help other service members who get hurt in military hospitals.

“Right thing to do”

“We labored on this for a long, long time, and we decided that the right thing to do here was to protect the rights of other people who go into the military and are signing away their rights to get good health care in the military system,” said Witt’s brother-in-law, Carlos Lopez, of Salt Lake City.

“So we’re hoping, we’re praying, that his case could be the one that changes everything.”

The Feres ruling grew out of the Federal Tort Claims Act of 1946, which allowed lawsuits against the government for negligent acts under certain circumstances.

Initially the law was interpreted to forbid lawsuits by military personnel and their families only for combat-related injuries and deaths, but the decision in Feres v. United States — involving a soldier who died in a barracks fire — widened that exclusion to bar any lawsuits over injuries “incident to military service.”

The effort to change the law has gotten wide support from military officers and veterans groups, including seven that have filed briefs in Witt’s case to demonstrate the public’s interest to the justices.

“We’ve given them a case that presents them with the best opportunity to fix this in a long time,” said Jamal Alsaffar, whose Austin, Texas, law firm represents the family.

“They’re the ones who broke it, so they are in the best position to fix it.”

Harsh dissension

At least one of the justices criticized the law the last time a related case came before the high court. The 1987 case reaffirmed the military hospitals’ protections in a 5-4 ruling, with conservative Justice Antonin Scalia writing a harsh dissenting opinion.

“Feres was wrongly decided and heartily deserves the widespread, almost universal criticism it has received,” he wrote.

The law has survived myriad legal challenges and various congressional efforts to overturn it. In 2009, a bill introduced in the House — in the name of a 29-year-old Marine sergeant and Iraq War veteran who died of skin cancer his family claims was misdiagnosed — achieved some traction, but not enough.

Republican lawmakers derided the measure, saying that opening the military to lawsuits would be expensive and benefit trial lawyers more than service families.

The Congressional Budget Office estimated it would cost the government an average of $135 million every year in claims. If the law were made retroactive, the estimated price tag was $2.7 billion over the next 10 years.

Feres supporters also say doing away with it would give a soldier who loses a limb to a doctor’s mistake, for example, a shot at a lucrative lawsuit, while another who loses a limb in combat would be limited to whatever help the Pentagon provides.

“This could demean injuries suffered in combat by providing the soldier injured on the battlefield with administrative compensation while the soldier injured in a military hospital could seek a multimillion-dollar damage award in federal court,” U.S. Rep. Trent Franks, R-Ariz., said in a committee hearing on the 2009 bill.

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